Sunday, June 3, 2018

Anxiety is a
frequent co-occurring (comorbid) problem for children and youth with autism spectrum disorder (ASD). Although
prevalence rates vary from 11% to 84%, most studies indicate that approximately
one-half of autistic children meet criteria for at least one anxiety disorder.
Despite promising advances in the research and practice
literature, our understanding of the phenomenology and treatment of
anxiety in ASD remains somewhat limited. Importantly, there is a paucity of
information on the difference between ASD and non-ASD populations in regards to
the manifestation of anxiety symptoms. Understanding more about the factors
triggering and maintaining anxiety in ASD, and how autistic children and their
families experience, think and speak about anxiety, will help inform the
development and implementation of autism-specific interventions for anxiety.

An exploratory study
published in the journal Autism
reported on a series of 5 focus groups with parents of children and adolescents
with ASD and anxiety as a first step in identifying the triggers, behavioral
signs and cognitive processes associated with anxiety. Seventeen mothers of 19
children with a diagnosis of ASD participated in the focus groups. All children
(12 boys and 7 girls) had received ASD diagnoses from local clinical services
and were reported to experience significant levels of anxiety that had an
impact on their functioning.The following is a summary
of key themes identified by parents in relation to triggers, symptoms and
impact of anxiety in their children with ASD.

Anxiety
triggers/Stressors

1. Change or disruption to
routine.

2. Confusion and worries
about social and communication situations.

3. Specific fears and
phobias.

4. Sensory oversensitivity
and overstimulation.

5. Being prevented from
preferred repetitive behaviors and interests.

6. Too many demands or
expectations.

Presentation of
anxiety

1. Increase in challenging
behavior.

2.
Avoidance/withdrawal/escape.

3. Increase in levels of
arousal.

4. Increase in sensory,
repetitive, and ritualistic behavior.

5. Physical sensations
associated with anxiety.

6. Cognitive distortions
and errors in thinking.

Impact of anxiety

1. Personal distress in
children, parents, and siblings.

2. Increase in challenging
behavior and stereotyped behaviors.

3. Restriction of
activities/opportunities.

4. Negative impact on
quality of life for child and family.

Parent Perspectives

Across groups, parents
gave markedly similar descriptions of the triggers and behavioral signs
associated with anxiety. Parents’ perspectives on the anxieties of their children
indicate that there are many overlaps with anxiety as experienced in the
general population. Shared triggers included social worries, specific phobic
stimuli, and expectations that are, or are perceived to be, too demanding.
Common features of the presentation of anxiety include an increase in arousal
and avoidance/escape behaviors.

There were, however, a
number of autism-specific triggers and symptoms of anxiety identified in
children with ASD. Key features were the intensity, pervasiveness and
persistence of the anxiety. Changes and disruptions to routines, sensory
sensitivities and social difficulties associated with difficulties in perspective-taking
and social expectations appeared to be ASD-specific triggers. Situations that
were reported to trigger anxiety often reflected autism-related difficulties in
processing style or sensory sensitivity. The majority of comments about the
presentation of anxiety fell into the categories of challenging behavior and
avoidance/withdrawal, indicating that behavioral manifestations are the major
expressions of anxiety in children with ASD. When asked about their anxious
thoughts, the most prominent theme that emerged was the difficulty that
children with ASD have in expressing their anxiety verbally, particularly at
times of severe distress. Although this is also occurs with many typically
developing children, it may be a particular difficulty for children and youth with ASD
given the challenges they face in understanding and expressing emotions and
pragmatic language difficulties. In addition to similar descriptions of the
triggers and behavioral signs associated with anxiety, the impact of anxiety
was reported to be often times more substantial than the impact of ASD itself.

Implications

Although this study did
not specifically address assessment and intervention/treatment issues, several
implications in these areas emerged. For example, when parents and children
with ASD are asked to describe their experiences in a semi-structured,
non-directed manner, they largely focus on features more specific to the ASD
population that are not typically measured on most standard anxiety measures.
Although there are broad-based measures that evaluate emotional/behavioral
difficulties in children with neurodevelopmental disabilities, a significant
gap remains in the resources available to clinicians and researchers for
measuring ASD-specific aspects of anxiety. This argues for the inclusion of
observational methods in the assessment of anxiety: using multiple informants,
multimodal assessment techniques, and methods.

Identification of specific
triggers/stressors and presentation of anxiety in children with ASD can help
educators and interventionists improve programs and services for this group of
students. These findings may also be useful for clinicians working with
children and youth with ASD, particularly those utilizing CBT as a treatment
approach. Although recent randomized controlled trials suggest that enhanced
and adapted CBT can successfully treat anxiety disorders in high functioning
children with ASD, it is unclear which adaptations are critical or which
modifications are required for which anxiety disorder. Nevertheless, the authors note that their
findings support the view that adaptations to CBT, such as adding ASD-specific
components to the treatment protocol, are important, relevant and acceptable to
parents of children with ASD.They also
caution that even though CBT can be an effective means of treating anxiety in
youth with ASD, clinicians may need to consider whether CBT is the most
appropriate intervention or whether other approaches such as behavioral
strategies or environmental modifications may be more suitable, as accessing or
modifying cognitions may prove too challenging for some youth with ASD. Yet, CBT
is clearly an effective intervention for many autistic children and youth, and the
involvement of parents can further improve outcomes.

Recommendations for future
research include focusing on larger groups and control samples, and systematically
investigating the link between ASD cognitive processing styles and anxiety. The
authors propose that further exploration of the similarities and differences
between shared and ASD-specific triggers, manifestations, and effects of
anxiety using a variety of methodologies will contribute to the development of
more appropriate assessment measures and ASD-specific models of anxiety which
can then guide treatment for more effectively.

Ozsivadjian, A., Knott, F.,
& Magiati, I. (2012). Parent and child perspectives on the nature of
anxiety in children and young people with autism spectrum disorders: a focus
group study. Autism,
16, 107-121. DOI: 10.1177/1362361311431703

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